Why aren't doctors revealing their diagnoses? During my work in Northern Ireland on access to justice for older adults, we realized that the doctor's diagnosis is a key opportunity for families to receive early advice about "non-medical" planning, such as arranging for powers of attorney or other arrangements for financial management, while the patient has adequate cognition to help with decision-making. If communication of the diagnosis is delayed, the window for effective participation in planning may also be lost.

In analyzing relationships that may gain greater legal recognition, the authors examine the possible influence of statutory obligations, including Pennsylvania's filial support laws used to impose care obligations on adult children, or more recent statutes granting visitation rights to grandparents:

"Probably the strongest candidate for full family status is the linear family group composed of grandparent(s), parent(s), and child(ren). It is clear that this familiar type of extended family can function satisfactorily to fulfill family functions. Further, the genetic bond among the members, together with well-defined family roles, reinforces already existing norms of commitment and caring. The primary challenge for these extended families may be the creation of networks with other similar families pursue their goals of increasing public support and attaining official family status.More complex multigenerational groups pose a greater challenge because they are less familiar to the public and less likely to be bound by family-commitment norms than are linear family groups. Partly for this reason, regulators may find it more difficult to verify the family functioning of these unconventional multigenerational groups."

Ever been asked that question "how's your health?" (or any of the derivative questions, such as "how are you" (to which you typically respond, "fine, thank you and you?") or "how are you feeling?") You typically respond "fine, thanks", unless you are talking to your doctor, and then you may be more specific. But typically when a person is asked to describe her health, she may not list her chronic conditions that may come with aging.

Jane Brody's March 2, 2015 blog post on Healthy in a Falling Apart Sort of Way opens with her relating how, when filling out a medical questionnaire asking her to evaluate her health, she typically checks the box "healthy." After sharing how she really is with the readers, she then turns to a discussion of how health is really measured, quoting some experts that "note that the ability to continue to participate in society might be more important than measured gains in health. The ability to cope with life’s ailments might be more a more important and realistic measure of health than complete recovery."

She then considers modern medicine "[t]he widespread belief that medicine today has the potential to prevent most health problems or detect them early enough for a cure has succeeded in “medicalizing” modern life and raising the costs of medical care to unsustainable levels." She looks at the different theories regarding preventive care, testing and early intervention. She reviews the W.H.O. factors for using health care and ends with advice from one of the experts who suggests using caution and good judgment when choosing medical care.

NAELA welcomes the effort to try to make the eligibility criteria for pension and other benefits administered by VA objective and transparent, but we believe that these proposed regulations, if implemented, would cause substantial harm to wartime Veterans, their spouses, and dependents and will not solve the serious issue of unscrupulous organizations taking advantage of potential beneficiaries by selling inappropriate annuities or trusts.

In addition, we express the serious concern that the proposed rule’s 3-year look-back period and transfer of assets penalty exceed statutory authority, opening up VA to future litigation and causing additional uncertainty for Veterans and their families.

There is an interesting new YouTube video available, with charismatic, high-profile actors encouraging all of us to initiate "The Talk" about how we -- or our loved ones -- want to handle the possibility, indeed probability, that someday we will need long-term care. Rob Lowe, Maria Shriver, Maggie Gyllenhaal, Angela Bassett, Zachary Quinto and Jim Nantz admit the difficulties of talking about growing old, often using vivid tidbits from their own lives or families to emphasize the importance of breaking past the barriers of denial.

I like the video. It is simple, direct. But, at the same time, I find the initial video, while interesting, to be a lacking in specifics about what it means to "talk" about long-term-care planning. The 2-minute video is actually part of a series created by Genworth, the major seller of long-term care insurance, and if you hit the right (wrong?) buttons you are directed to Genworth websites that offer more details, especially about -- surprise, surprise -- buying long-term care insurance.

I suspect that many people will panic if they hear "pay some money now" in order to buy LTC insurance, as even a part of the "solution." See what you think:

One of the declared purposes of modern federal law setting threshold standards for eligibility for Medicaid for long-term care is "protection of the community spouse" from impoverishment. At least that's a declared objective of amendments to federal law, passed by Congress in 1988. As one of Dickinson Law's Elder Protection Clinic clients once observed, "slower" impoverishment isn't the same as protection. States have choices to make within federal guidelines about minimum and maximum sums, about how much money community spouses can keep when their loved ones apply for Medicaid for long-term care.

Allowing the spouse of a person in a nursing home to keep enough money to live on independently is, in many ways, a moral issue. But in a tight budget year in Connecticut, it's a fiscal issue.

A proposal that would increase the minimum assets that a spouse living in the community can keep - from $23,844 to $50,000 – in order for his or her partner to be eligible for Medicaid nursing home care is being backed by elder advocates, who say the increase would help seniors, especially women, remain able to live independently. But the move is being opposed by the Department of Social Services on the grounds it will shift millions in costs to the state-funded Medicaid program.

The proposal would affect couples with combined assets of between $23,844 and $100,000....

It will be interesting to see whether this bill has traction, and whether other states are also willing to step up to the financial plate.

Attorney and author Steve Dale has published a new book, Achieving Independence- A Guide to Creating an Estate Plan Which Ensures Quality of Life for You and Your Loved One with a Disability. According to the author

The primary purpose of this guide is to assist families in the planning process of creating a special needs trust for a loved one with a disability. Stephen shares with the reader his experience as an attorney that has focused primarily on estate planning for persons with disabilities and their families for the past 25 years. He also illustrates some of the challenges that persons with disabilities and their families face by sharing his experiences growing up in California’s State Hospital System as a child of three generations of institutional workers and later as a Psychiatric Technician giving direct care in a variety of psychiatric hospitals for 17 years.

Stephen and his office developed the Achieving Independence System to educate clients on key issues and decisions commonly encountered in creating a special needs trust so clients can be better prepared before meeting with their attorneys and advisors to create a team that best serves their needs. After the plan is created, an effective plan will assist the trust management team to focus on what is really important; to assist a person with a disability to live as independently as possible and to experience a quality of life that many persons who are not disabled take for granted. In essence to achieve the highest level of independence possible free from abuse and neglect.

The book runs 133 pages and is available from Amazon as a paperback for $20.00. Steve's Independence project is explained on his website, Achieving Independence. Full disclosure, Steve is a friend and a regular speaker at Stetson's annual Special Needs Conference.

Colleagues in the U.K., Dr. Una Lynch in Northern Ireland and Dr. Karim Hadjri in Lancashire, England, shared information on an opening for a new academic position in aging research. The listing nicely illustrates how global research into aging issues is multi-faceted, challenging and not solely focused on health care:

The postholder will be an established researcher in Architecture or an Ageing related discipline, with demonstrable evidence of developing and promoting their cognate research or knowledge transfer/consultancy activity to high-level peers. The appointee will work closely with the Project Coordinator of ODESSA. ODESSA - Optimising care delivery models to support ageing-in-place: towards autonomy, affordability and financial sustainability, is a Europe-China initiative funded by China NSF and research funding agencies from four EU countries (UK, France, Germany and The Netherlands) under the Understanding Population Change theme. The project partners are Tsinghua University from Beijing, China, and Université Paris Dauphine and Université CNRS/Paris I-Panthéon Sorbonne from Paris, France. ESRC is the UK funding agency and the programme manager. The total value of the project is around GBP 1m and duration is 36 months starting on 1st March 2015.

The successful candidate will have an established international reputation in research (or knowledge transfer/consultancy), research project coordination and management, with demonstrable high impact areas that are supported and evidenced in leading peer-reviewed journals and extant literature. Educated with a PhD in architecture, built environment, or ageing related disciplines, and evidence of knowledge of architecture or ageing related disciplines research methods as well as a proven track record of meeting project deliverables and deadline is essential for this position.

University of Florida Professor Stephen M. Golant has a new book, Aging in the Right Place. The gerontologist advocates examining a host of modern options, and urges resistance to an overly simplistic mantra of "aging in place" as the only goal. For example, he examines assisted living, co-housing, supported "independent living" environments, the "village" movement and CCRCs.

“It’s not an all-or-nothing situation, obviously,” Golant said in an interview about aging-in-place. “But I just wanted to point out the imperfections, and the weaknesses in some of the arguments. . .I want to point out that sometimes there’s too much hype.”

It’s the sort of hype that has surrounded what he calls the New Gerontology, a long running trend that sometimes seems to imply that if people follow certain regimens of diet, physical exercise, social activity and cognitive training, they might avoid aging altogether.

As I have also suggested here, it is important for individuals and families to be realistic about what it will take to stay at home safely, making it important to be open to a larger definition of "home" in order to emphasize better quality of life.

In Draper v. Colvin, petitioner sought judicial review of SSA's denial of her application for SSI benefits. Her claim was sympathetic, as "[e]ighteen-year-old Stephany Draper suffered a traumatic brain injury in a car accident in June 2006."

In an admittedly "hard line" ruling on March 3, the 8th Circuit rejected her argument that her parents' intent to establish a valid third-party-settled special needs trust, using proceeds from a settlement of a personal injury suit on her behalf, should permit her to claim SSI.

The ruling means that over $400,000 will be treated as "available resources," thus requiring spend down before she would be eligible for benefits. The court explained (minus citations):

Admittedly, some evidence in the record supports Draper's claim that her parents intended to act in their individual capacities. Draper's parents identified themselves individually as settlors and trustees, and the trust document explicitly states that it was established “pursuant to 42 U.S.C. § 1396p(d)(4)(A)," a provision which notes that a third party, such as a parent, must create the special needs trust for the benefit of the disabled person. Nevertheless, as discussed [earlier in the opinion], other facts provide substantial evidence to support the conclusion that Draper's parents acted using the power of attorney when establishing the trust.

"The health consequences of marital dissolution are well known, but little work has examined the impact of health on the risk of marital dissolution. In this study we use a sample of 2,701 marriages from the Health and Retirement Study (1992–2010) to examine the role of serious physical illness onset (i.e., cancer, heart problems, lung disease, and/or stroke) in subsequent marital dissolution due to either divorce or widowhood. We use a series of discrete-time event history models with competing risks to estimate the impact of husband’s and wife’s physical illness onset on risk of divorce and widowhood.

We find that only wife’s illness onset is associated with elevated risk of divorce, while either husband’s or wife’s illness onset is associated with elevated risk of widowhood. These findings suggest the importance of health as a determinant of marital dissolution in later life via both biological and gendered social pathways."

The use of trusts has evolved from means of transferring property to mechanisms for managing assets and more recently, to will substitutes for avoiding probate and simplifying post-death transfers. But lawyers increasingly use revocable trusts in planning for possible client incapacity to avoid the costs and publicity associated with custodianship and guardianship. State-level reforms of trust law to accommodate older uses of these devices are not, however, well-suited to this newer use of trusts, and this lecture will examine those reforms in this context.

Professor Sitkoff was the youngest professor to receive a chair in the history of Harvard Law School. He previously taught at New York University School of Law and at Northwestern University School of Law. After graduated from the University of Chicago Law School with High Honors, he clerked for then Chief Judge Richard A. Posner of the United States Court of Appeals for the Seventh Circuit. Professor Sitkoff is an active participant in trust and estates law reform. He is a liaison member of the Joint Editorial Board for Uniform Trusts and Estates Acts within the Uniform Law Commission and has been a member of several drafting committees for acts involving trusts and estates matters. Sitkoff is also a member of the American Law Institute’s Council and has served on the consultative groups for the Restatement (Third) of Trusts and the Restatement (Third) of Property: Wills and Other Donative Transfers.

Word from Dick Kaplan is that Rob's presentation will be available (eventually) via a recording, and his presentation will also be captured as an article in University of Illinois' Elder Law Journal.

My students often ask why all casebooks can't be as engaging to read as the "Dukeminier" text on Wills, Trusts & Estates -- and I suspect one reason is that Rob Sitkoff, although uniquely prolific and gifted, is still only human and cannot write them all!

Postscript: I asked Rob to send me something other than his "official" Harvard photo. The one above seems to capture his spirit and the smile I sometimes detect in his footnotes.

This week, the Supreme Court will hear oral arguments on the latest challenge to the ACA, in King v. Burwell. The New York Times offers historical perspective about an earlier journey to enact federal legislation that mandated the nation's first broad health care coverage, the Medicare program:

Lyndon B. Johnson was often derided for being egocentric, but when it came time to sign his landmark bill creating Medicare, 50 years ago this July, he graciously insisted on sharing the credit with the 81-year-old Harry Truman. At almost the last moment, Johnson decided to change the location from Washington to Truman’s presidential library in Independence, Mo.

During the ceremony, Johnson noted that in 1945, the newly installed President Truman had called for national health insurance, planting “the seeds of compassion and duty which have today flowered into care for the sick, and serenity for the fearful.” Johnson then presented his host with the nation’s first Medicare card. Deeply moved, Truman later wrote in a letter to Johnson that the ceremony was “the highlight of my post-White House days.”

Texas attorney Renée C. Lovelace has literally written the book -- a guidebook -- on Pooled Trust Options. Renée was a recent guest speaker at Penn State's Dickinson Law, appearing before students in an advanced seminar on planning techniques. Indeed, our students had specifically asked to hear from experienced practitioners on special needs trusts, and with the help of the National Elder Law Foundation we were able to host a nationally known speaker to do just that.

Renée (third from the left, in blue) helped our students identify appropriate uses of pooled trusts, such as where the beneficiary's needs could be uniquely well-served by a trustee who is familiar with the challenges sometimes encountered in managing assets on behalf of persons with disabilities.

While the special needs beneficiary may be frustrated by a manager's handling of "his" (or "her") money, sometimes it is the family that has questions about application of the law. Recently I was reading a New Jersey case decision, where a family was challenging the state's attempt to seek reimbursement for medical and care expenses expended by the state, following the death of their disabled daughter. At the core of the dispute was what appeared to be a misunderstanding on the part of the family about the nature of their daughter's special needs trust, which they were describing as a pooled trust. The court pointed out, that in the absence of a nonprofit manager, the trust could not be deemed a (d)(4)(C) trust or "pooled" trust, that would have allowed assets remaining after the death of the daughter to stay in the trust for the benefit of other disabled persons, rather than be subject to the state's reimbursement claim.

Thus, the case is a reminder that pooled trusts, properly created and managed are usually drafted as special needs trusts (SNTs). However, not all SNTs are pooled trusts. Or as Renée explains so well in her thorough guidebook:

USA Today reportson home care workers "joining a nationwide movement" to raise wages, with rallies planned for "more than 20 cities in the next two weeks."

As described by journalist Paul Davidson,

"Like the fast food workers, the 2 million personal care and home health aides seek a $15 hourly wage and the right to unionize, which is barred in some states. Their median hourly wage is about $9.60 and annual pay averages just $18,600 because many work part-time, according to the Labor Department and National Employment Law Project. That puts the industry among the lowest paying despite fast-growing demand for home-based caregivers to serve aging Baby Boomers over the next decade.

'Home care providers living in poverty don't have a stable standard of living so they can provide quality care,' says Mary Kay Henry, president of the Service Employees International Union, which is spearheading the home care aides' movement and backed the fast-food worker strikes."

According to a representative of "Home Care Association of America, which represented agencies that employ personal-care aides," companies attempt to "balance the ability to keep care affordable with attracting employees."

Thanks to Dickinson Law 3L student Jake Sternberger for pointing me to this news item.

The National Consumer Law Center (NCLC)is offering a free webinar on "Medical Debt: Overview of New IRS Regulations and Industry Best Practices" on March 4, 2015 from 2 to 3 p.m. Eastern Time.

The hosts describe the webinar as follows:

This webinar will present an overview of the IRS final regulations governing financial assistance and collection policies of nonprofit hospitals. The regulations require nonprofit hospitals to have written financial assistance policies; regulate debt collection by nonprofit hospitals and third partyagencies; and prohibit the imposition of "chargemaster" rates to patients eligible for financial assistance.

Find out how to use the regulations to help clients who owe medical debts to nonprofit hospitals and protect them from lawsuits, liens, and credit reporting damage. The webinar will also review the voluntary best practices on medical account resolution issued by the Healthcare Financial Management Association.

The first White House Conference on Aging Regional Forum was held on February 19, 2015 in Tampa Florida. The morning featured comments by the WHCOA Executive Director Nora Super and remarks by Cecilia Munoz, Assistant to the President and Director, Domestic Policy Council. Two panels followed, with comments by panelists on the 4 topics of emphasis for the 2015 WHCOA, healthy aging, long term services and supports, retirement security and elder justice. In the afternoon, participants were divided into working groups for those 4 topics, where they discussed priorities, obstacles, and actions. Representatives from each working group presented the group's topic recommendations in a closing panel presentation moderated by Kathy Greenlee, Administrator for the Administration on Community Living and the Assistant Secretary for Aging. In person attendance was invitation only, but the event was live webcast through HHS. The next regional forum is set for Phoenix, Arizona on March 31st. Visit the WHCOA forums website a day or so before the event to register for the live webcast.

As the long-predicted aging tsunami hits, are there enough doctors to meet the need? Not in Montana, as demonstrated by a two-part story from NBC News:

"There is no part of life in McCone County, Montana, where the community's age has not begun to show. Farmers have gone gray. There were some dozen funerals last winter. Each year makes more widows. Nearly 25 percent of McCone County's 1,700 residents are already over 60, a bellwether for changes that will soon roll across Montana. State projections show a quarter of Montanans will be seniors by 2030, twenty years before the same demographic shift hits the nation as a whole.

Montana policymakers have watched that shift coming toward them, knowing it brings more older, potentially sicker patients to a largely rural medical system in which providers and specialists are already scarce. Seniors here often travel an hour or more for 'emergency' care, and nursing home beds are dwindling, particularly in the sparsest areas.

In the face of these changes, Charlie Rehbein, head of the Montana Office on Aging, asks, 'How do we provide services to them?'"